Conjunctivitis in Children >1 month-16 years - Guideline for the Management of
|Last review: 14/02/2019|
|Next review: 14/02/2022|
|Approved By: Improving Antimicrobial Prescribing Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2019|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Guideline for the Management of Conjunctivitis in Children >1 month-16 years
Conjunctivitis in Children >1 month-16 years
For neonates with conjunctivitis see Guideline for the management of neonatal conjunctivitis (ophthalmia neonatorum)
Exclude other serious causes of a red eye – see diagnosis section of full guideline, then
Acute severe conjunctivitis: symptoms <3 weeks duration; red eye, mild/moderate discharge (subjective clinical assessment) AND any of severe pain; photophobia; or severe eyelid oedema.
Acute non severe conjunctivitis: symptoms <3 weeks duration; red or pink, gritty eye, minimal/moderate discharge; no photophobia; minimal pain.
Chronic conjunctivitis: symptoms >3 weeks duration.
If periorbital cellulitis is present or eye movements are painful see LTHT guideline for diagnosis and management of orbital cellulitis.
For acute severe infection chloramphenicol 0.5% eye drops or chloramphenicol 1% eye ointment is first line empirical treatment. Fusidic acid 1% (Fucithalmic®) eye drops are used in patients who are allergic/intolerant to chloramphenicol, are pregnant or have a personal or family history of blood dyscrasias.
Hyperacute conjunctivitis or other suspected Neisseria gonorrhoeae infection – see empirical treatment section.
Conjunctivitis presents as an acute, red, gritty, sticky eye(s), usually bilateral but may be sequential; purulent discharge with crusty lids and diffusely injected conjunctiva. The rapidity of progression and severity of symptoms determines classification, treatment and investigation - see background.
With a unilateral red eye it is important to exclude serious causes e.g. glaucoma, keratitis and iritis. These should be suspected if any of the following features occur:
If there are NO features to suggest a serious cause of red eye exclude:-
The characteristic features of conjunctivitis are:-
Recommendation: For acute non-severe conjunctivitis swabs for microbiological investigation are generally unnecessary. However swabs of the eye are recommended in acute severe and chronic conjunctivitis to identify the infective cause.
Recommendation: In hyperacute conjunctivitis: send a swab for microscopy and bacterial culture and an APTIMA swab for gonococcal nucleic acid detection and a swab in viral transport medium for adenoviral PCR.
Recommendation: In chronic conjunctivitis send a swab for bacterial culture and an APTIMA swab for Chlamydia nucleic acid detection.
Recommendation: Children who require contact lenses should not wear their lenses until all symptoms of infection have resolved and for at least 24 hours after the treatment has been completed.
Recommendation: Lubricant eye drops/gel to reduce discomfort. Hypromellose 0.3% drops or Carbomer 0.2% eye gel instilled three to four times a day or more often are suitable lubricants.
Recommendation: Secretions from the lid and lashes should be removed with cotton wool soaked in water.
Recommendation: Removal of pseudomembranes: Very painful conjunctivitis can be caused by mucous membranes forming under the eyelids. Ophthalmology should assess for pseudomembranes and remove physically.
|Empirical Antimicrobial Treatment|
Recommendation: Topical antimicrobials should not be routinely used for non-severe acute conjunctivitis.
Recommendation: Patients not prescribed topical antimicrobials should be advised to return or be reviewed in 3 days if symptoms are worse. Patients should be informed that viral conjunctivitis may take 7-12 days to resolve and bacterial conjunctivitis about 7 days without treatment.
Recommendation: For acute conjunctivitis requiring treatment, first line therapy is chloramphenicol 0.5% eye drops (initially one drop is instilled into the affected eye(s) four times a day for 7 days) OR 1% eye ointment (applied three times a day for 7 days.)
Recommendation: For patients who are allergic/intolerant to chloramphenicol, are pregnant, have a history, or family history of blood dyscrasias or would prefer a twice daily treatment fusidic acid 1% (Fucithalmic®) is an alternative. A 7 course is recommended.
Recommendations: For hyperacute conjunctivitis or confirmed gonococcal conjunctivitis prescribe topical treatment as above in addition to Cefotaxime (infants 1-3 months old) OR Ceftriaxone (infants 3 months – children 16 years old).
Ceftriaxone * dose:
These doses should be given by intravenous infusion only, over 60 minutes.
A single dose only should be given if there is no corneal involvement.
If the cornea is involved, treatment should be for three days.
In a Cochrane review, Meta-analysis of early (days 2 to 5) and late (days 7 to 10) clinical and microbiological outcomes revealed that topical antibiotics are of benefit in improving early clinical (RR 1.24, 95% CI 1.05 to 1.45) and microbiological (RR 1.77, 95% CI 1.23 to 2.54) remission1. These benefits were reduced but nonetheless persisted for late clinical (RR 1.11, 95% CI 1.02 to 1.21) and microbiological (RR 1.56, 95% CI 1.17 to 2.09) remission1. No serious adverse outcomes were reported in either the active or placebo arms of the trials1. The authors conclude that although conjunctivitis is a self-limiting condition the use of antibiotics is associated with significant improved rates of clinical and microbiological remission although the advantages at day 6-10 is negligible. There is further evidence that delaying treatment by 3 days and only prescribing if symptoms persist produces no difference in duration of moderate symptoms (3.3 days [risk ratio 0.7, 95% confidence interval 0.6 to 0.8], delayed antibiotics 3.9 days [0.8, 0.7 to 0.9]), but reduces antibiotic use2.
Clinical Knowledge Summary (CKS) recommend that as most patients get better without treatment, complications are low and 10% of patients suffer adverse reactions to treatment that antibiotics should only be provided if:-
Third generation cephalosporins are the current treatment of choice for Neisseria gonorrhoeae infections as resistance rates are very low to these agents4.
In conclusion if conjunctivitis is mild it is worth not treating with antibiotics, prescribing lubricants and counseling patients on hygienic measures to prevent spread with a proviso to return if symptoms do not improve in 3 days. For moderate to severe symptoms treatment should be prescribed.
|Directed Antimicrobial Treatment (when microbiology results are known)|
When the results of microbiology samples are known it may be necessary to amend therapy. Discuss with microbiology as necessary.
Neisseria gonorrohoea or Neisseria meningitidis isolated - treat according to recommendations for gonococcal conjunctivitis.
|Duration of Treatment|
Acute conjunctivitis: 1 week.
Hyperacute conjunctivitis - see empirical treatment section.
Recommendation: If conjunctivitis persists for more than two weeks the patient must be re-evaluated.
Referral to an Ophthalmologist should be considered to clarify diagnosis and rationalise therapy. Swabs for bacteria and Chlamydia should be taken, if not done already. Treatment will depend on results of the swabs. If Chlamydia is present the family must be referred to a community paediatrician for systemic treatment and child protection assessment.
For chronic conjunctivitis refer to an ophthalmologist. N.B. Molluscum contagiosum will not resolve until the lesion is removed.
|Target patient group:||Any paediatric (non- neonatal) patient with conjunctivitis|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
- Sheikh A, Hurwitz B, van Schayck CP, McLean S, Nurmatov U. Antibiotics versus placebo for acute bacterial conjunctivitis. Cochrane database of systematic reviews (Online). 2012;9:CD001211.
- Everitt HA, Little PS, Smith PW. A randomised controlled trial of management strategies for acute infective conjunctivitis in general practice. Bmj. Aug 12 2006;333(7563):321.
- Clinical_knowledge_summary. CKS Acute infective conjunctivitis. 2012.
- Agency HP. GRASP 2011 Report: The Gonococcal Resistance to Antimicrobials Surveillance Programme: Health Protection Agency; 2012.
A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
C. Expert consensus.
D. LTHT consensus.
Improving Antimicrobial Prescribing Group
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